Provider Demographics
NPI:1841745205
Name:HYDERKHAN, PENELOPE (RBT)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:
Last Name:HYDERKHAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 N RANCHO DR STE 108
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3151
Mailing Address - Country:US
Mailing Address - Phone:702-990-0326
Mailing Address - Fax:
Practice Address - Street 1:3650 N RANCHO DR STE 108
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3151
Practice Address - Country:US
Practice Address - Phone:702-990-0326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLBA0821103K00000X
NVRBT-16-22232103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVLBA0821OtherNV ABA BOARD